What to write
Item 3. Nature and significance of the local problem.
Item 4. Summary of what is currently known about the problem, including relevant previous studies.
Explanation
The introduction section of a quality improvement article clearly identifies the current relevant evidence, the best practice standard based on the current evidence and the gap in quality. A quality gap describes the difference between practice at the local level and the achievable evidence-based standard. The authors of this article describe the problem and identify the quality gap by stating that “Examination of a 10-month sample revealed only 63% of the patients received antibiotics within 60 minutes of arrival and that the benchmark of <60 minutes and that delays in delivering antibiotics led to poorer outcomes.”1 The timing of antibiotic administration at the national level compared with the local level provides an achievable standard of care, which helps the authors determine the goal for their antibiotic administration improvement project.
Providing a summary of the relevant evidence and what is known about the problem provides background and support for the improvement project and increases the likelihood for sustainable success. The contextual information provided by describing the local system clarifies the project and reflects upon how suboptimal care with antibiotic administration negatively impacts quality. Missed diagnoses, delayed treatments, increased morbidity and increased costs are associated with a lack of quality, having relevance and implications at both the local and national levels.
Improvement work can also be done on a national or regional level. In this case, the term ‘local’ in the SQUIRE guidelines should be interpreted more generally as the specific problem to be addressed. For example, Murphy et al describe a national initiative addressing a healthcare quality issue.2 The introduction section in this article also illuminates current relevant evidence, best practice based on the current evidence, and the gap in quality. However, the quality gap reported here is the difference in knowledge of statin use for patients at high risk of cardiovascular morbidity and mortality in Ireland compared with European clinical guidelines: “Despite strong evidence and clinical guidelines recommending the use of statins for secondary prevention, a gap exists between guidelines and practice … A policy response that strengthens secondary prevention, and improves risk assessment and shared decision-making in the primary prevention of CVD (cardiovascular disease) is required.”2
Improvement work can also address a gap in knowledge, rather than quality. For example, work might be done to develop tools to assess patient experience for quality improvement purposes.3 Interventions to improve patient experience, or to enhance team communication about patient safety4 may also address quality problems, but in the absence of an established, evidence-based standard.
Example
Central venous access devices place patients at risk for bacterial entry into the bloodstream, facilitate systemic spread, and contribute to the development of sepsis. Rapid recognition and antibiotic intervention in these patients, when febrile, are critical. Delays in time to antibiotic (TTA) delivery have been correlated with poor outcomes in febrile neutropenic patients.2 TTA was identified as a measure of quality of care in pediatric oncology centers, and a survey reported that most centers used a benchmark of <60 minutes after arrival, with >75% of pediatric cancer clinics having a mean TTA of <60 minutes…
The University of North Carolina (UNC) Hospitals ED provides care for ∼65 000 patients annually, including 14 000 pediatric patients aged, 19 years. Acute management of ambulatory patients who have central lines and fever often occurs in the ED. Examination of a 10-month sample revealed that only 63% of patients received antibiotics within 60 minutes of arrival …1
Training
The UK EQUATOR Centre runs training on how to write using reporting guidelines.
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